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PSEN reviews > PSEN Ptosis and Mastopexy > Flashcards

PSEN Ptosis and Mastopexy Flashcards

Review key points about Ptosis and Mastopexy. Content from PSEN, ACAPS, and Pearls

1
Q

Define the different grades of breast ptosis

A
  • 1 = nipple with or above IMF
  • 2 = nipple below IMF
  • 3 = on most dependent portion of the breast
  • Pseudoptosis = nipple at or above IMF with increased IMF to nipple distance with majority of breast tissue below IMF
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2
Q

What is the vascular supply to the breast?

A
  • Internal mammary, lateral thoracic, thoracoacromial, thoracodorsal, intercostals 3-5.
  1. (medioinferior) Internal mammary-anterior intercostal system
  2. (superolateral) Lateral thoracic and minor contributors including axillary artery
  3. (periareolar) anastomosis between the two systems
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3
Q

What are classifications of ptosis?

A

Glandular = breast migrates inferiorly en bloc

Parenchymal = high IMF and inferior hypoplasia (tuberous or constricted breast deformity)

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4
Q

What is the “three-step principle” when assessing the breast?

A
  1. skin envelope
  2. Breast conus
  3. Breast footprint
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5
Q

What measurements do you need to obtain during your assessment of patients for breast surgery?

A

Notch to nipple, nipple to IMF, base width, degree of ptosis, NAC diameter

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6
Q

What are risk factors for developing ptosis?

A

Age, significant weight loss, higher BMI, larger cup size, number of pregnancies, smoking

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7
Q

Is breast feeding associated with increased breast ptosis?

A

no

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8
Q

What are the characteristics of a tuberous or constricted breast?

A
  1. high IMF
  2. narrow base
  3. herniation of breast parenchyma into areola
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9
Q

What maneuvers need to be performed for treating a tuberous breast deformity?

A

Lower IMF, increase inferior pole volume, scoring breast parenchyma, NAC repositioning, decreasing areola size

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10
Q

What are the characteristics of Massive Weight Loss patient breasts?

A
  • Grade III ptosis
  • medialization of the nipple-areola complex
  • Lateralization of the breast mound
  • Extension to a lateral axillary fat roll
  • Lowered inframammary fold
  • Asymmetrical volume loss
  • Deflated and flat appearance of the breast (particularly a flat upper pole)
  • Excess skin laxity
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11
Q

Three key principles of mastopexy

A
  1. repositioning the NAC
  2. Parenchymal shaping
  3. Skin resection
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12
Q

When treating a tuberous breast, what maneuver will decrease the risk of a double-bubble deformity?

A

Parenchymal scoring. This releases constricting bands. Double bubble occurs when the natural IMF is not adequately obliterated.

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13
Q

What is the most common complication of a donut (periareolar) mastopexy?

A

widening of the areola. This is minimized by using a permanent Gore-Tex suture in a Wagon-wheel technique and limiting the skin resection outside the NAC to 2:1

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14
Q

What is the dominant blood supply for a breast superior pedicle?

A

Internal thoracic superficial branch from the 2nd interspace

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15
Q

What is the dominant blood supply for a breast inferior pedicle?

A

Internal thoracic superficial branch from the 4th interspace

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16
Q

What is the dominant blood supply for a breast medial pedicle?

A

Internal thoracic superficial branch from the 3rd interspace

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17
Q

What is the dominant blood supply for the breast lateral pedicle?

A

superficial branches of the lateral thoracic artery

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18
Q

What is the most common medial innervation to the NAC?

A

3rd and 4th intercostal nerve anterior cutaneous branches

19
Q

What is the predominant innervation of the NAC?

A

Lateral cutaneous branches of the 4th intercostal sensory nerve

20
Q

What is the sensory innervation to the upper pole of the breast?

A

Supraclavicular nerves from the 3rd and 4th branches of the cervical plexus

21
Q

What is the sensory innervation to the medial and lateral breast?

A

anterior and lateral cutaneous branches of the intercostal nerves II through VII

22
Q

What are indications that a free nipple graft may be needed?

A
  1. 1500g or more reduction 2. Nipple transposition >25cm 3. Smokers 4. Diabetes
23
Q

How do you determine the bra cup size?

A

Measure the diameter of the chest under the breast (band size). Measure the breast diameter at the point of most projection. 1 inch difference = A cup 2 inch = B cup 3 inch = C cup 4 inch = D cup 5 inch = DD cup

24
Q

How do you manage a dusky nipple postoperatively?

A
  1. Release the sutures holding the NAC 2. If that doesn’t work, return to OR to check pedicle for kinking 3. Apply nitro paste to nipple 4. Convert to Free-nipple graft if needed 5. HBO
25
Q

What is the most common planning error with mastopexy and the most difficult to correct post-op?

A

Placing the nipple too high (star-gazing nipple)

26
Q

Relaxation of what structure allows for ptosis?

A

Attenuation of Cooper’s ligaments

27
Q

When should a staged mastopexy/augmenation procedure be considered?

A

When more than 3cm of nipple elevation is required

28
Q

When combining augmentation and mastopexy, what are general recommendations for the NAC to sternal notch distance?

A

<225cc implant = NAC at 21cm 250-325cc implant = NAC at 22cm > 350cc implant= NAC at 23 cm

29
Q

How to do you prevent the crossing the IMF with the vertical limb during a vertical mastopexy?

A

The lower border of the mosque design should stop 2-6cm above the IMF

30
Q

Describe the Benelli Round-block technique

A
31
Q

Describe the Wagon-wheel suture technique for peri-areolar mastopexy. What type of suture is used?

A

Gore-Tex Suture in a wagon-wheel pattern as described by Hammond

32
Q

What are the different types of periareolar mastopexy?

A
  1. Benelli Round-block
  2. Spear concentric
  3. Hammond interlocking Gore-tex
33
Q

What are some types of vertical mastopexy?

A
  1. Hall-Findlay medial pedicle
  2. Closure of medial and lateral pedicles
  3. Hildago Y-scar
  4. Lassus - superior pedicle
  5. Lejour - superior pedicle + liposuction
34
Q

What are principle features of the vertical mastopexy?

A
  • The IMF is raised
  • The breast width is decreased
  • The breast will have an inverted shape that settles over time
35
Q

What are some modified vertical mastopexy techniques?

A
  1. Marchach - short horizontal scar
  2. Chiari - L scar
  3. Regnault - B scar

(vertical limb with short horizontal scar)

36
Q

Describe different inverted T mastopexy skin patterns:

A
37
Q

Augmentation can only correct _____ ptosis

A

Mild

38
Q

Your patient needs a 2-stage aug-mastopexy. Which procedure do you do first?

A

Mastopexy

39
Q

Your patient is having a one-stage aug-mastopexy. Which proceudre do you do first?

A

Augmentation

40
Q

What risks of mastopexy should you discuss with your patient?

A
  • Nipple loss
  • Decreased sensation to the nipple
  • inability to breast feed
  • asymmetry
  • scarring
  • recurrence
  • need for reoperation
41
Q

What is the advantage of aug-mastopexy versus mastopexy alone?

A

improvement of upper pole fullness

42
Q

What is a common complication of mastopexy and breast reduction over time?

A

Bottoming-out AKA pseudoptosis (increase of NAC to IMF length)

43
Q

What type of pedicle should you use in secondary mastopexy?

A
  • blood supply to the nipple-areola complex should generally rely on a medial, superior, superomedial, or superolateral pedicle
  • do not use an inferior pedicle - due to gravity causing soft-tissue thinning and atrophy in the inferior pole
44
Q

What are increased risks of Aug-mastopexy?

A
  • more rapid recurrence of ptosis (weight of the prosthesis places additional tension at the site of incision)
  • Nipple malposition
  • Nipple ischemia (The larger the prosthesis, the greater the adverse effect on vascularity)
  • Skin flap loss
  • Prosthesis infection/exposure
  • “Resultant deformities”
  • NO increased risk of loss of nipple sensation

PSEN reviews (18 decks)

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